OXYGEN IS ESSENTIAL: A POLICY BRIEF

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1 This resource has been developed for DECISION-MAKERS OXYGEN IS ESSENTIAL: A POLICY BRIEF Adara Development In many low- and middle-income countries, newborns, children, and pregnant women die needlessly each year from a dangerous condition called hypoxemia, or a low concentration of oxygen in the blood. Hypoxemia can be caused by a range of illnesses and complications including pneumonia, neonatal infections, premature birth, and obstetric emergencies. Other conditions, such as noncommunicable diseases and pandemic disease outbreaks, can also result in hypoxemia. Most cases of hypoxemia can be easily diagnosed and managed with functioning oxygen delivery systems, including pulse oximetry and oxygen therapy. Pulse oximeters are used to help health workers know who needs oxygen and how much oxygen to give. However, the high prevalence of serious conditions resulting in hypoxemia underscores the need to better prioritize oxygen s availability and integration in national and subnational health care systems. Expanding access to oxygen delivery can save countless lives from a wide range of conditions. Increased commitment is needed by decision-makers to include oxygen technologies and supplies in national policies, plans, and budgets. Prioritizing oxygen delivery is one of the most effective and worthwhile investments to save the lives of newborns, children, and pregnant women suffering from hypoxemia. IN THIS BRIEF Health benefits of incorporating oxygen therapy into health systems Integration of oxygen delivery into existing policies and programs Oxygen therapy is extremely limited in most low- and middle-income countries (LMIC), even though it is considered an essential medicine by the World Health Organization (WHO) and identified as one of 20 priority lifesaving treatments for newborns, children, and pregnant women. Recent studies indicate that nearly half of hospitals in low-resource settings have inconsistent or no supply of oxygen, and only half have pulse oximeters. Many health authorities assume that the costs associated with equipment purchase, maintenance, and provider training make expanding access to oxygen delivery unrealistic or unaffordable. OXYGEN: A HEALTH PRIORITY Oxygen therapy can prevent deaths from common conditions that affect the most vulnerable in low- and middleincome countries: newborns, children, and pregnant women. For health decision-makers looking for practical ways to improve health outcomes, oxygen delivery should be a key consideration for inclusion in national and subnational policies, programs, and budgets. Overview of oxygen delivery systems Guiding questions on increasing access to and utilization of oxygen delivery systems What policymakers and health decisionmakers can do to scale up access to oxygen delivery

2 OXYGEN IS ESSENTIAL: A POLICY BRIEF PAGE 2 The health benefits of oxygen delivery: lives saved Given the wide range of conditions that lead to hypoxemia, improved access to oxygen therapy and pulse oximetry can benefit all populations. However, its impact is particularly significant in improving maternal, newborn, and child health (MNCH). Newborn health impact More than half of all neonatal deaths globally are due to preterm birth complications, neonatal pneumonia, and neonatal sepsis. Antibiotics with full supportive care for severe neonatal infections which includes oxygen therapy could prevent an estimated 400,000 neonatal deaths each year. Child health impact Pneumonia is the leading infectious cause of death in children younger than five years, and causes 15 percent of child deaths around the world. Approximately 13 percent of children with pneumonia develop hypoxemia; between 1.5 and 2.7 million hypoxemic pneumonia cases present to health facilities each year. If both pulse oximetry and oxygen therapy were consistently available, up to 120,000 child deaths could be averted each year in the 15 countries with the highest pneumonia burden. Maternal health impact Approximately 15 percent of all pregnant women develop a potentially life-threatening complication that may require emergency obstetrical intervention including oxygen for survival. Oxygen therapy is commonly recommended for obstetric emergencies including hemorrhage, pulmonary embolism, eclampsia, sepsis, and heart failure. Cesarean sections represent a high proportion of the total emergency surgical and trauma care procedures in LMIC. Furthermore, availability of oxygen for pregnant women is important not only to protect maternal health, but also to help avoid intrapartum-related injury to or asphyxia in the newborn. Integrating oxygen delivery into policies and programs The optimal strategy for policy development takes a system-wide approach that considers not only how oxygen delivery can be incorporated into programs, but also into efforts focused on strengthening service delivery, procurement, and supply chain management. Global strategies, guidelines, and protocols provide direction on how oxygen delivery can be incorporated into existing health programs, including MNCH programs. Global policies In June 2017, WHO included a new listing for oxygen in its Model List of Essential Medicines and Model List of Essential Medicines for Children, identifying oxygen as a medicine essential for the management of hypoxemia. This change clarifies oxygen s importance as a medical treatment that should be widely available in health facilities everywhere. In 2012, WHO, the United Nations Population Fund, and the United Nations Children s Fund selected oxygen as one of 20 medicines included in a list of priority lifesaving medicines for women and children for its impact on reducing maternal, newborn, and child morbidity and mortality. In 2015, oxygen technologies and supplies were placed in the WHO/United Nations Population Fund/ United Nations Children s Fund interagency list of priority medical devices for essential interventions for reproductive, maternal, newborn, and child health. WHO oxygen treatment protocols are provided in a number of global guidelines including an oxygen therapy for children manual for health workers. Further directions are also integrated into guidelines for various health areas, including acute respiratory infections, neonatal conditions, chronic respiratory diseases, and emergency and essential surgical care. The 2016 WHO standards for improving the quality of maternal and newborn care in health facilities include benchmarks for availability of oxygen technologies and supplies. See Global Guidelines for Shaping National Oxygen Policy KEY STATS 15% Pneumonia causes 15 percent of under-five deaths around the world 120,000 Pulse oximetry and oxygen therapy could save up to 120,000 children s lives each year Up to 400,000 Antibiotics and full supportive care for severe neonatal infections which includes oxygen therapy has the potential to prevent up to 400,000 neonatal deaths each year 15% 15 percent of pregnant women develop a complication that may require emergency intervention including oxygen therapy

3 OXYGEN IS ESSENTIAL: A POLICY BRIEF PAGE 3 National policies A 2016 analysis by PATH found that more than 30 percent of national essential medicines lists across 105 countries did not include oxygen at all and roughly half listed oxygen only for anesthesia. Ensuring that oxygen is represented on a country s essential medicines list is a critical step toward improving access to oxygen therapy. Further action is needed to ensure inclusion of oxygen delivery in national and subnational health policies that will support reliable access to oxygen delivery systems within health facilities. Other national guidance documents that should incorporate oxygen delivery include MNCH strategies, standards of care, and operational guidelines focused on improving service delivery at the facility level. Oxygen technologies and supplies, including pulse oximeters, oxygen blenders, flowmeters, and patient interfaces, should be integrated into essential equipment lists, regulatory policies, procurement and supply chain management guidelines, standard treatment protocols, training manuals, health facility assessments, and maintenance procedures. Oxygen delivery systems: benefits and challenges Oxygen is an internationally available medicine that can be dispensed through a range of delivery methods, giving decision-makers the flexibility to choose the right medical oxygen supplies for their context (see Figure 1). Research suggests that the cost benefits of oxygen therapy with pulse oximetry are comparable to other interventions that are widely recommended to reduce mortality from pneumonia, including vaccines. Because oxygen therapy can also be used to treat any form of hypoxemia regardless of its underlying cause, it has the potential to reduce disease burden among many patient groups. Increasing investments in oxygen delivery within the health system can impact health outcomes across all populations. While cylinders do not require an electrical supply, they do require refills from a supplier, which incurs transportation costs and supply chain management considerations. Gradian Health Systems FIGURE 1 COMMON SOURCES OF OXYGEN MEDICAL GAS CYLINDERS CONCENTRATOR CENTRAL PIPELINE SYSTEM Oxygen medical gas is available to health facilities in multiple formats, including cylinders, concentrators, and central pipeline systems.

4 OXYGEN IS ESSENTIAL: A POLICY BRIEF PAGE 4 Oxygen delivery systems Multiple sources are available for supplying oxygen medical gas in health facilities. These include cylinders, concentrators, and central pipeline systems. Many decision-makers in LMIC choose pressurized oxygen cylinders over concentrators or central pipeline systems because they are initially less expensive. While cylinders do not require an electrical supply, they do require refills, which incurs transportation costs and supply chain management considerations. Central pipeline systems require significant capital expense. Health facilities should consider a medical oxygen supply strategy after careful evaluation of the total cost of ownership and advantages and disadvantages of the variety of oxygen delivery options. Over time, the use of cylinders may become more expensive for a facility compared to oxygen concentrators, depending on the oxygen demand and power availability. Concentrators use a power supply to concentrate oxygen from ambient air, resulting in an inexhaustible source of oxygen for multiple patients at the same time. In Papua New Guinea, oxygen concentrators, together with pulse oximetry, a reliable power supply, regular maintenance, and training for providers, cost US$50 per disability-adjusted life year (DALY) averted. Innovations are under way to develop oxygen concentrators that would reliably deliver oxygen therapy at low cost without relying on consistent electricity, pointing to potential future reductions in overall cost of oxygen delivery systems. Pulse oximetry for diagnosis and management To increase the effectiveness of oxygen delivery systems, decision-makers should scale up pulse oximetry for diagnosis of blood oxygen levels in all facilities with oxygen therapy. Pulse oximeters (see Figure 2) are simple to use and can guide decisions on how much, and for how long, oxygen therapy should be FIGURE 2 PULSE OXIMETERS 60 Pulse oximeters are simple devices used to detect hypoxemia and guide decisions on how much, and for how long, oxygen therapy should be delivered. Pulse oximeters come in multiple formats, including bench-top (left) and handheld (right).

5 OXYGEN IS ESSENTIAL: A POLICY BRIEF PAGE 5 delivered. Preterm newborns are especially vulnerable to injury from too much oxygen, and monitoring with pulse oximetry is vital to avoid serious complications, such as blindness. Pulse oximetry gives health workers the confidence to administer oxygen therapy only when needed and monitor the patient to ensure the correct level of oxygen is administered. Systems challenges Recent studies have shown that even where oxygen and pulse oximetry are available in operating theaters, patients with hypoxemia in other wards may not be receiving oxygen therapy when they need it. For example, a child suffering from pneumonia may need oxygen therapy in the pediatric ward, where oxygen delivery systems are not available. Decision-makers must prioritize oxygen delivery systems that ensure technologies and supplies are available where they are needed, and used consistently and correctly including training, maintenance, and supervision so that every patient receives the proper amount of oxygen at the right time. NEXT STEPS FOR SCALING UP OXYGEN DELIVERY Prioritizing oxygen delivery is one of the most effective ways to save the lives of newborns, children, and pregnant women suffering from the range of conditions that cause hypoxemia. Expanding access to oxygen delivery systems will benefit other populations, including those suffering from noncommunicable diseases, trauma, and other disorders. To scale up access to oxygen delivery, health policymakers and decision-makers should: Prioritize funding for and integration of oxygen delivery in health facilities. Incorporate oxygen and pulse oximetry into existing health policies, including national maternal, newborn, and child health strategies, treatment guidelines, and essential medicines and equipment lists. Ensure responsible management of oxygen technologies and supplies, and strengthen health worker training and capacity for proper use and maintenance of equipment. Gather data on oxygen, pulse oximetry, and hypoxemia indicators to increase understanding of hypoxemia burden and oxygen therapy need, which can help ensure access to oxygen delivery for the full range of indications recommended by WHO and national treatment guidelines. ADDITIONAL RESOURCES The complete Oxygen Primer includes the following materials: Oxygen Is Essential: An Issue Brief } Oxygen Is Essential: A Policy Brief Global Guidelines for Shaping National Oxygen Policy Oxygen Technologies and Supplies Guiding Questions for Oxygen Scale-up Mapping a Future for Oxygen Access for All: Ethiopia s Experience Oxygen Messaging Map It is available at sites.path.org/oxygentherapy-resources/ oxygen-primer